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ONE of the many rewarding aspects
of practising medicine is the
ability to engage with people from
a wide range of socio-economic
and cultural backgrounds.

But communication difficulties
can arise and these have the potential to
negatively impact patient care. In dealing with
limited English proficiency to motor speech
disorders, there are a number of
pitfalls to avoid.

Language barriers

An obvious, and increasingly common, risk
area is treating patients who speak little or no
English. This can cause significant difficulties.

When faced with a language barrier
between you and your patient, the ideal
solution is to have a certified interpreter
present. If so, be sure to record the interpreter’s
details within your contemporaneous medical
entry. However, logistical difficulties often
mean that a professional is not readily
available. In these circumstances, first check if
your hospital has a policy on interpreter and
translation services and be sure to follow it. If
an interpreter is not readily available, consider
whether it is possible to defer your interaction with the patient until one can be arranged. You
may want to discuss your decision to postpone
with senior colleagues to ensure they are also
content it does not compromise patient care.

Help from friends or family

In a busy hospital setting it is often tempting
just to “make do” with whatever resources are
available. Doctors often encounter relatives
or friends who are keen to be helpful and
translate for patients. This may seem like the
most convenient (not to mention cost-free)
solution but there are pitfalls. The first and
fundamental issue to consider is your patient’s
right to confidentiality and your obligation not
to disclose their personal information to a third
party without consent.

Another relevant consideration is the lack
of any training or accreditation for such an ad
hoc interpreter. Do they understand the
important points you are making? Even if they
do, can you be sure they are relaying the
information accurately? Although this is
important in all aspects of medical care, it is
essential when you are seeking your patient’s
informed consent. MDDUS has encountered
several cases of complaints and accusations
of clinical negligence in which patients have
stated they were not aware of all the risks
because they had not been communicated by
the interpreter.

It is also important to keep in mind that
friends or relatives of a patient are not
impartial and may have their own agenda
which may not align with your patient’s. As a
consequence, they may filter the information
they communicate to the patient, or amend
responses to suit their own motivation.

That said, there is no specific rule
preventing you from seeking their assistance. A
patient may be adamant that they want a
particular person to translate for them, or
circumstances may justify seeking their
assistance. In these cases it is important to
make a comprehensive note explaining that a
friend/relative is acting as interpreter. Include
their name and a brief record of why you
believe it is appropriate or necessary, and bear
in mind the pitfalls mentioned above.

Smart apps

Who needs a human interpreter when you’ve got technology, right? Given the difficulties
in securing a trained professional, clinicians
are increasingly turning to online translating
tools. Perhaps the most recognised is Google
Translate, which has been gaining in popularity
over recent years. Although it can be useful
in social settings, Google Translate has not
been validated for use in the medical setting
and is not endorsed by the NHS. As a result,
there is a significant risk of error in using it
to facilitate medical consultations. Online
translating tools often use a literal approach
and direct translation of words can fail to take
into account the broader context and may alter
meaning. Similarly the English translation of a
patient’s response may not accurately reflect
their intention.

In the absence of any validated online
translating tool it is perhaps best to avoid
relying on them. Not only is there a
significant risk of a potentially serious error,
but there’s a good chance using such online
tools will breach your hospital’s interpreter/
translation policy. Instead, focus on liaising
proactively with your hospital’s interpreter
service to find out about their availability and
any practical help they may be able to offer in
more urgent cases. Your hospital may have a
list of multi-lingual staff members who are
able to assist in urgent situations. Finally, if
you find yourself in difficulty don’t forget the
immense skills and experience of your
colleagues – seek guidance from other
doctors, nurses and ancillary staff.

Capacity

At the beginning of any patient interaction it
is essential to establish whether they have
capacity to engage in their medical care and
provide consent if required. If a patient lacks
capacity for the specific decision required, you
should establish whether they have made a
valid advance decision or appointed a power of
attorney for healthcare decisions. Also check
whether the court has appointed an individual
to make decisions on their behalf. If in doubt,
seek assistance from senior colleagues, your
hospital legal department or medical defence
organisation, being sure to carefully document
any decision making.

If there is no advance decision, power of
attorney or court-appointed decision-maker,
you should act in the best interests of your
patient. The relevant legislation is the Mental
Capacity Act 2005 (England and Wales), the
Adults with Incapacity Act 2000 (Scotland) and
the Mental Capacity Act (Northern Ireland)
2016. You should be familiar with GMC
guidance, Consent: patients and doctors
making decisions together, and their website
features a very helpful interactive online tool
for when you are unsure if a patient has
capacity.

Motor speech disorders

A patient’s ability to communicate may be
affected by a motor speech disorder. A common
one is dysarthria which can be caused by
factors such as stroke, head injury and facial
nerve damage.

In isolation, dysarthria does not affect a
patient’s ability to understand. If the level of
dysarthria affects your ability to communicate
with your patient consider any means by which
you could overcome the difficulties. This may
include seeking assistance from the speech
and language team, trying to remove
background noise, deferring non-urgent
decisions if the dysarthria is likely to resolve
shortly, or using additional means of
communication such as writing.

For more specific guidance, contact the
MDDUS advice line on 0333 043 4444.

The Medical and Dental Defence Union of Scotland Registered in Scotland No 5093 at Mackintosh House, 120 Blythswood Street, Glasgow, G2 4EA. The MDDUS is not an insurance company. All the benefits of MDDUS are discretionary as set out in the Articles of Association.